POLYMYALGIA RHEUMATICA


I. Clinical features

  1. Age >50y
  2. Pain & morning stiffness x 30min or longer (in 2 or more of: neck, shoulders, torso, hip), usually chronic
  3. Elevated ESR (> 40; often >100)
  4. Normal CPK
  5. Normal mm. strength though "breakaway muscle pain"
  6. Fever, malaise, fatigue, weight loss
  7. Anemia, altered LFT's (esp. alk-phos), elevated CRP, polyclonal gammopathy
  8. 25% will develop temporal arteritis

II. Treatment

  1. Low-dose Corticosteroids typically used
    1. Generally given 10-20mg/d then slow taper, e.g. drop dose 2.5mg/d/month till at 10mg/d, then decrease by 1mg/d/month till off
    2. Flares ,ay occur during taper; use symptoms/ESR to guide alterations in tx
    3. Often treated for as long as 2 years
  2. Methotrexate
    1. 72 pts with PMR, all on prednisone 25mg/d tapering over 6mos (but capable of being restarted as symptoms dictated), randomized to methotrexate (10mg Qwk + folinic acid 7.5mg Qwk) vs. placebo x 48wks; at 18mos, sig. fewer methotrexate pts were on corticosteroids (12% vs. 47%) or had one or more flare-ups (47% vs. 73%) (Ann. Int. Med. 141:493, 2004--JW)
  3. In a systematic review of 13 randomized and 17 non-randomized studies, treatment with prednisone or prednisolone at doses of < 10mg/d was associated with higher incidence of relapse than higher doses, but there was no benefit with doses > 15mg/d compared with lower doses.  Relapses were less frequent with slow taper of corticosteroids than with sudden discontinuation.  Methotrexate at 10mg Qwk added to corticosteroid therapy further reduced incidence of relapses.  Infliximab added to prednisone did not provide added benefits.(Arch. Int. Med. 169:1839, 2009-AFP)